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Union Calendar No. 600

99th Congress, 2d Session - - - - - - - - - - - - - House Report 99-1016

INVESTIGATION OF THE CHALLENGER

ACCIDENT

REPORT

OF THE

COMMITTEE ON

SCIENCE

AND TECHNOLOGY

HOUSE

OF REPRESENTATIVES

NINETY-NINTH CONGRESS

SECOND SESSION

OCTOBER 29, 1986.-Committed to the Committee of the Whole House on the State of the Union and ordered to be printed

64-420 0

U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON

: 1986

COMMITTEE ON SCIENCE AND TECHNOLOGY

DON FUQUA, Florida, Chairman

ROBERT A. ROE, New Jersey GEORGE E. BROWN. JR.. California MANUEL LUJAN, JR.; New Mexico ROBERT

S. WALKER, Pennsylvania

JAMES

H. SCHEUER, New York

MARILYN LLOYD, Tennessee

TIMOTHY E. WIRTH, Colorado

DOUG WALGREN, Pennsylvania

DAN GLICKMAN, Kansas ROBERT A. YOUNG, Missouri

HAROLD

L. VOLKMER, Missouri

BILL NELSON, Florida STAN LUNDINE, New York RALPH M. HALL, Texas DAVE McCURDY, Oklahoma NORMAN Y. MINETA, California BUDDY MAcKAY,'. Florida TIM VALENTINE, North Carolina HARRY M. REID, Nevada ROBERT

G. TORRICELLI, New Jersey F. JAMES SENSENBRENNER,

JR.,

CLAUDINE SCHNEIDER, Rhode Island

SHERWOOD L. BOEBLEKT, New

York TOM LEWIS, Florida DON RI'ITER, Pennsylvania SID W. MORRISON. Washinaton Wisconsin

RON PACKARD, California

JAN MEYERS, Kansas ROBERT C. SMITH, New Hampshire PAUL B. HENRY, Michigan HARRIS W. FAWELL, Illinois WILLIAM W. COBEY,

JR., North Carolina JOE BARTON, Texas D. FRENCH SLAUGHTER, JR., Virginia DAVID

S. MONSON, Utah

RICK BOUCHER, Virginia TERRY BRUCE, Illinois RICHARD H. STALLINGS, Idaho BART GORDON, Tennessee JAMES A. TRAFICANT, JR., Ohio JIM CHAPMAN, Texas

HAROLD

P. HANSON, Executive Director

ROBERT C. KETCHAM, General Counsel

REGINA A. DAVIS, Chief Clerk

R. THOMAS WEIMER, Republican Staff Director

CHALLENGER ACCIDENT REPORT STAFF TASK GROUP

ROBERT C. K~HAM, General Counsel

RADP~RD BYERLY, Jr.

RONALD E. WILLIAMS

PATRICIA G. GARFINKEL

A. SCOTT CROSSFIELD

CAROLYN C. GREENFELD DAVID D.

CLEMENT

SHIRLEY J. WATSON ROBERT E.

PALMER

GEORGE S. KOPP HARRY

S. DAWSON, Jr. HARRIET J.

SMITH

NEUON L. MILDER CAROLYN J. RADABAUGH

JAM= PAUL

GLORIA J. DUNDERMAN

'Ranking Republican Member. "Serving on Committee on the Budget for 99th Congress (11)

LETTER OF SUBMITTAL

U.S. HOUSE OF REPRESENTATIVES,

Washington, DC, October 29, 1986.

Hon. THOMAS P. O'NEILL, Jr.,

The Speaker of the US. House of Representatives, Washington, DC.

DEAR MR. SPEAKER:

By direction of the Committee on Science and Technology, 1 hereby submit the Committee's investigative report on the Chal- lenger accident. The report was approved by the Committee on Oc- tober

7, 1986. The report was carried out under the direction of the Ranking Majority Member, Robert

A. Roe, who chaired the hear- ings and instructed the Committee staff assigned to the investiga- tion. Sincerely, DON FUQUA,

Chairman.

Enclosure.

(111)

LETTER OF TRANSMITTAL

U.S. HOUSE OF REPRESENTATIVES, COMMITPEE

ON SCIENCE AND TECHNOLOGY,

Washington, OC, October 29, 1986.

To Robert

A. Roe, Ranking Majority Member, Committee on Science and Technology.

DEAR MR. CHAIRMAN:

I am forwarding this investigative report on the Challenger Acci- dent prepared

at your request. On your instructions, the staff has carefully reviewed the infor- mation made available to the Committee and prepared the neces- sary findings and recommendations. The task was enormous and has been done in

a careful and painstaking manner. I am especial- ly grateful

to all the staff which is listed on the inside cover of the report for their professional and thorough application to this im-

portant report. We worked in a collegial manner and on a com- pletely bipartisan basis. I particularly want to thank the three group leaders, Ron Williams, Terry Dawson and Harriet Smith who headed up the respective subgroups for the Accident, the Tech- nical, and the Management Issues. Sincerely,

ROBERT C. KETCHAM, General Counsel.

CONTENTS

Page I. INTRODUCTION .........................................

11. CONCLUSIONS ...........................................

V. THE ACCIDENT ........................................................................ ................................. 39

111. C~MPILATION OF ISSUES, FINDINGS, AND RECOMMENDATIONS ..........................

IV. B~CKGROUND ........................................................................ ................................... 35 ................................ 64 ................................... 65 VII. CASING JOINT DESIGN ........ ............................. ......................

VIII. LAUNCH OPERATIONS .........

Ix. DEFINITION OF TERMS AND

X. APPENDICES .........................

V-A ..............................

lVlll vrrr V-G ... .............. . ................................................................. VIII-B .............. ........ .. ..... ............. ............. ....

VIIIC .......... .......... .................... .................. ............................... .....................

VIII-D ............................................................ .................................................

VIII-H ......... ................................................. ...................................................

VIII-I ........................................................................

VIII-J .............................. ................................ ................................................

VIII-K . . . . . . .. . . . . . .. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . ................................... ,.,., ......,,....

Page

285 286 288 290 292 319 321 327 369 376 278 280 384 387 393 395 406 417 425 428 434 438 442

Union Calendar No. 600

99~~ CONGRESS REPORT

2d session } HOUSE OF REPRESENTATIVES I gg-io16

INVESTIGATION OF THE CHALLENGER ACCIDENT

OCTOBES 29, 1986.-Committed to the Committee of the Whole House on the State of the Union and ordered to be printed Mr. FUQUA, from the Committee on Science and Teshnology, submitted the following

REPORT

I. INTRODUCTION

On January 28,

at 11:39 a.m., the Space Shuttle Challenger and

its crew suffered a tragic accident during launch. That same day the House of Representatives adopted

H. Res. 361 which expressed the profound sorrow of the House for the tragedy and offered con- dolences to the families

of the Challenger crew members. During consideration of the resolution Chairman Fuqua informed the full House of Representatives that, in conformance with

its oversight responsibilities, the Committee on Science and Technolo- gy would conduct a comprehensive investigation into the cause of this accident. This report is the result of the Committee's inquiry. It contains the best efforts of the Committee to review the work of the Presi- dential Commission on the Space Shuttle Challenger Accident (hereafter referred to

as the Rogers Commission) and the work of the National Aeronautics and Space Administration (NASA) in in- vestigating the causes of the accident, and reviewing the recom- mendations to resume safe flight. In addition to reviewing the five volumes

of the Rogers Commis- sion Report, the Committee also had direct on-line access to the entire Rogers Commission data base, which included full-text and document retrieval capability. The findings and recommendations contained in this report are the product of the Committee's own extensive hearing record,

' Report of the Presidential Commission on the Space Shuttle Challenger Accident, Volumes I- V, Washington, D.C., June 6, 1986. (Hereafter referred to as Rogers Commission Report.) (1) 2

which includes materials submitted for the record, staff investiga- tions, interviews, and trips. It should be understood that the role of this Committee

is differ- ent from that of the four-month Rogers Commission. The Commit- tee, which authorized the funds and reviewed the lengthy develop- ment process which led to the successful Shuttle program, has

a re- sponsibility to insure that the tragic accident, and those events that led up to it, are understood and assimilated into all levels and activities of NASA

so that safe manned space flight can be re- sumed. In carrying out its annual authorizing responsibilities, the Com- mittee endorses the programs and activities of NASA, and func- tions

as a key player in the legislative activities of our federal system. As part of the fulfillment of this role, the Committee has reviewed the report of the Rogers Commission, called upon numer- ous witnesses, and utilized many members of its

staff to prepare and review the material that has produced this report. The Committee has been most fortunate in its work due to the diligent and thorough investigation undertaken by the Rogers Com- mission and the NASA investigation panels that supported the Commission. The Commission's exhaustive efforts to achieve com- pleteness

as it came to grips with a very complex technical and management system are very commendable, and will serve

as a model for future Presidential Commissions. The Committee wishes to express

its appreciation for the assist- ance of the House Administration Committee, the Rogers Commis- sion staff, and the Justice Department's Office of Litigation Sup- port, Civil Division. Each of these groups was very cooperative and helpful in providing the access to, and equipment for, the Challeng-

er accident data base needed by the Committee to do its work. In addition, the Committee very much appreciates the assistance of

NASA personnel who responded to numerous requests for briefings and documents during the course of the investigation.

11. CONCLUSIONS

In execution of its oversight responsibilities, the Committee on Science and Technology has conducted

a thorough investigation of the Challenger accident. Although the Committee's concern and evaluation in this report are related specifically to the safe and ef- fective functioning of NASA's Space Shuttle program,

it should be understood that our larger objective and greater responsibility are to insure that NASA,

as the Nation's civilian space agency, main- tains organizational and programmatic excellence across the board. What we

as a Committee, NASA as an agency, and the Nation as

a whole, also must realize is that the lessons learned by the Chal- lenger accident are universally applicable, not just for NASA but for governments, and for society. We hope that this report will serve this much larger purpose. The Committee's investigation included: ten formal hearings in- volving

60 witnesses; an extensive review of the report of the Rogers Commission along with its voluminous supporting appendi- ces and related reports by the investigation panels

at NASA, as

well as numerous briefings and interviews with NASA officials, contractor personnel, outside experts, and other interested parties. From the outset, the focus of the Committee's investigation has been on understanding each of the following:

What was the cause, or causes, of the Challenger acci- dent? Are there other inherent hardware or management-re-

lated deficiencies that could cause additional accidents in the future? What must be done to correct all of these problems so that the Space Shuttle can be safely returned to flight status?

The Committee found that NASA's drive to achieve

a launch schedule of

24 flights per year created pressure throughout the agency that directly contributed to unsafe launch operations. The Committee believes that the pressure to push for an unrealistic number of flights continues to exist in some sectors of NASA and jeopardizes the promotion of

a "safety first" attitude throughout the Shuttle program. The Committee, the Congress, and the Administration have played

a contributing role in creating this pressure. Congressional and Administration policy and posture indicated that

a reliable flight schedule with internationally competitive flight costs was a near-term objective. Pressures within NASA to attempt to evolve from an R&D agency into

a quasicompetitive business operation caused a realign- ment of priorities in the direction of productivity

at the cost of safety. (3) 4

NASA management and the Congress must remember the les- sons learned from the Challenger accident and never again

set un- reasonable goals which

stress the system beyond its safe function- ing. The Committee commends the work of the Rogers Commission and

its supporting panels at NASA. Their investigation and the re- ports that document their efforts are very broad in scope and ex- ceptionally detailed considering the time that was available to ac- complish their task.

As a rule, the Committee agrees with the findings reached by the Rogers Commission. However, there are areas where the Commit- tee either disagrees with

a Rogers Commission finding or with the relative importance that the Rogers Commission attached to that finding. Like the Rogers Commission, the Committee concluded that the Challenger accident was caused by

a failure in the aft field joint on the right-hand Solid Rocket Motor. Additionally, we agree with the Rogers Commission that this tragic accident was not caused by the Orbiter, the Space Shuttle Main Engines, the External Tank, the onboard payloads, the ground support equipment, or the other ele- ments of the Solid Rocket Boosters. We also agree that the failure of the joint was due to

a faulty design, and that neither NASA nor Thiokol fully understood the operation of the joint prior to the acci- dent. Further, the joint

test and certification programs were inad- equate, and neither

NASA nor Thiokol responded adequately to available warning signs that the joint design was defective. In concurrence with the Rogers Commission, the Committee con- firms that the safety, reliability, and quality assurance programs within

NASA were grossly inadequate, but in addition recommends that

NASA review its risk management activities to define a com- plete risk management program. The Committee also agrees that

a thorough review must be conducted on all Criticality 1 and 1R items and hazard analyses; a study should be conducted on how to provide Space Shuttle crews with a means of escape during con- trolled gliding flight; and

NASA's Shuttle management structure, safety organization, communications procedures, and maintenance policies should

be carefully scrutinized and improved. In other areas, the Committee reached somewhat different con- clusions than the Rogers Commission:

The Rogers Commission concluded that

NASA's decision- making process was flawed. The Committee does agree that the Marshall Space Flight Center should have passed along to higher management levels the temperature con- cerns that Thiokol engineers raised the night before the launch of Mission 51-L. However, the Committee feels that the underlying problem which led

to the Challenger acci- dent was not poor communication or inadequate proce- dures

as implied by the Rogers Commission conclusion.' Rather, the fundamental problem was poor technical deci- sion-making over

a period of several years by top NASA

1 For the purpose of this report, a procedure is a formal set of instructions designed to guide and assist in the performance

of a technical or management function. 5

and contractor personnel, who failed to act decisively to solve the increasingly serious anomalies in the Solid Rocket Booster joints. Information on the flaws in the joint design and on the problems encountered in missions prior to

51-L was widely available and had been presented to all levels of Shuttle management. Despite the presence of significant amounts of information and the occurrence of

at least one detailed briefing at Headquarters on the difficulties with the 0-

rings, the NASA and Thiokol technical managers failed to understand or fully accept the seriousness of the problem. There was no sense of urgency on their part to correct the design flaws in the SRB.

No one suggested grounding the fleet, nor did

NASA embark on a concerted effort to remedy the deficiencies in O-ring performance. Rather, NASA chose to continue to fly with a flawed design and to follow

a measured, 27-month, corrective program. The Committee has more concerns than those expressed by the Rogers Commission about the relative

safety of the Space Shuttle Main Engine. We are impressed by the so- phistication and performance of the Main Engine, but are concerned that it may have inadequate safety margins to ensure continued safe operation. The Committee

is also concerned by the presence of persistent operating prob- lems with the engine (e.g., cracked turbine blades and de- fective hydraulic actuators and temperature sensors), and believes that

NASA should give serious consideration to not allowing the Main Engine to be operated (except in emergency situations)

at a thrust level greater than the standard

104 percent. On the other hand, should NASA de- termine that

a higher engine thrust setting is needed for programmatic reasons, the Committee believes that the space agency should take whatever actions

are required to ensure that adequate operating margins are present to maintain safety. The Committee has gone beyond the Rogers Commission in recommending

a new system specification to overcome the inadequacies of the landing gear, tire, wheel, brake and nose wheel steering systems. The Committee also con- cluded that orbiter landings appear to be high risk even under ideal conditions, which seldom occur. The Rogers Commission stated that "there appears to be

a departure from the philosophy of the 1960s and 1970s re-

lating to the use of astronauts in management positions."2 In contrast, after taking testimony from several former and current astronauts, the Committee could find no evi- dence that astronauts are denied the opportunity to enter management if they

so choose. On the other hand, prior to the STS

51-L accident, astronauts were not encouraged to enter management.

2 Rogers Commission Report, Volume I, p. 199.

6

In still other areas, the Committee has raised concerns that do not appear to have been addressed sufficiently by the Rogers Com- mission. We are concerned that:

There are numerous other recurrent hardware problems that are either not fully understood by

NASA or have not been corrected. The existing internal communication system is dissemi- nating too much information, often with little or no dis- crimination in

its importance. Accordingly, recipients have difficulty "separating the wheat from the chaff." Existing contract incentives used by

NASA do not ade- quately address or promote safety and quality concerns- most emphasis is placed on meeting cost and schedule re- quirements.

NASA does not yet understand how or why the deficien- cies in Solid Rocket Motor testing and certification went undetected in spite of the very comprehensive processes and procedures used by the agency to conduct and oversee these activities. The Committee

is concerned that without such an understanding,

NASA will not be able to protect against

a similar breakdown in its system of checks and balances in the future. The Committee has concerns regarding the safety of the Filament Wound Case Solid Rocket Booster now under de- velopment by

NASA, and recommends that the agency consider moving the heaviest Space Shuttle payloads to ex- pendable launch vehicles

so that there will be no need to use Filament Wound Case Boosters. The Committee is not assured that NASA has adequate technical and scientific expertise to conduct the Space Shuttle program properly. NASA has suffered staffing re- ductions in key areas over several years. Moreover, it loses

a significant number of technical/scientific personnel due to an imbalance between the government salary schedule and that of the private sector. The salary structure also in- hibits

NASA's ability to recruit top technical talent to re- place its losses. The record is not sufficient to warrant

a formal finding on this matter. However, the Committee in- tends to conduct an in-depth review of

NASA technical ability

in the next Congress.

On July

14, 1986, NASA submitted to the President a report on what actions the space agency plans to take in response to the rec- ommendations of the Rogers Commission. The Committee believes that the plans contained in this report are

a step in the right direc- tion. When fully implemented, these plans should substantially im- prove the safety of Space Shuttle flight operations. The Committee also endorses

NASAs decision to move the proposed date for the next Space Shuttle launch beyond June 1987.quotesdbs_dbs18.pdfusesText_24

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